Building Bridges Toward Common Goals - A Call for Greater Collaboration Between Public Health and Integrative, Complementary and Traditional Health Providers.

This commentary makes the case for greater collaboration between public health professionals and integrative, complementary and traditional health practitioners (ICTHP). Previous partnerships have been successful, and more such collaborative work is needed to help overcome division, enhance the health workforce, and move all involved toward shared goals. ICTHP providers may be uniquely able to work across ideological differences and engage individuals and communities who are less trusting of public health, including those who are vaccine hesitant. Diverse partnerships can be difficult to maintain, but the application of equitable processes may aid their success. In the face of highly complex public health challenges, partnerships with ICTHP are critical.

Definitions of Chronic Low Back Pain From a Scoping Review, and Analyses of Narratives and Self-Reported Health of Adults With Low Back Pain.

Among those with low back pain (LBP), individuals with chronic LBP (CLBP) face different treatment recommendations and incur the majority of suffering and costs. However, the way CLBP has been defined varies greatly. This study used a scoping review and qualitative and quantitative analyses of data from LBP patients to explore this variation. CLBP in most recent randomized controlled trials (RCTs) was defined by duration of pain, most commonly ≥3 months. However, individuals with LBP most often define CLBP by frequency. CLBP has also been defined using a combination of duration and frequency (16% of RCTs and 20% of individuals), including 6% of recent RCTs that followed the NIH Pain Consortium research task force (RTF) definition. Although not a defining characteristic of CLBP for individuals, almost 15% of recent RCTs required CLBP to have a healthcare provider diagnosis. In our LBP sample moving from ≥3 months to the RTF definition reduced the CLBP group size by 25% and resulted in a group that used more pain management options and reported worse health across all outcome measures. A pain duration definition offers ease of application. However, refinements to this definition (eg, RTF) can identify those who may be better intervention targets. PERSPECTIVE: This article presents the definitions used for CLBP by researchers and individuals, and the impact of these definitions on pain management and health outcomes. This information may help researchers choose better study inclusion criteria and clinicians to better understand their patients' beliefs about CLBP.

Longitudinal Associations of PROMIS-29 Anxiety and Depression Symptoms With Low Back Pain Impact in a Sample of U.S. Military Service Members.

INTRODUCTION: The Impact Stratification Score (ISS) is a measure of the impact of chronic low back pain (LBP) consisting of nine Patient-Reported Outcomes Measurement Information System (PROMIS-29) items, but no studies have examined the ISS or its association with psychological symptoms in military samples. This study examines longitudinal associations between psychological symptoms and the ISS among military service members. MATERIAL AND METHODS: The study involved secondary data analysis of a sample of active duty U.S. military service members aged 18-50 years with LBP (n = 733). Participants completed the PROMIS-29 at three time points during treatment: baseline (time 1, T1), week 6 of treatment (time 2, T2), and week 12 of treatment (time 3, T3). The impact of LBP was quantified using the ISS (ranging from 8 = least impact to 50 = greatest impact). Psychological symptoms were assessed as PROMIS-29 anxiety and depression scores. Separate autoregressive cross-lagged models examined reciprocal associations of ISSs with anxiety, depression, and emotional distress scores from T1 to T3. RESULTS: Within each time point, the ISS was significantly and positively correlated with anxiety and depression. In autoregressive cross-lagged models, anxiety and depression predicted the ISS at the next time point and associations were similar in magnitude (e.g., anxiety T2 to ISS T3: ß = 0.12, P < .001; depression T2 to ISS T3: ß = 0.12, P <.001). The ISS did not predict future depression or emotional distress scores at any time point, but the ISS at T2 was significantly, positively associated with anxiety scores at T3 (ß = 0.07, P = .04). CONCLUSION: Psychological symptoms consistently and prospectively predict the impact of LBP as measured by the ISS among service members undergoing pain treatment. The ISS may also be associated with future anxiety but not depression. PROMIS-29 anxiety and depression items may be useful adjunctive measures to consider when using the ISS to support LBP treatment planning and monitoring with service members.

Incorporating Complementary and Integrative Health Providers in the Public Health Pandemic Response: Lessons from COVID-19 and Recommendations for the Future from a Multidisciplinary Expert Panel.

Complementary and integrative health (CIH) providers, such as chiropractors and naturopathic doctors, have been an underutilized public health asset in the response to the COVID-19 pandemic. This article seeks to inform how they can be better integrated into future responses to public health emergencies. The authors convened an expert panel of ten CIH and public health practitioners and researchers for a daylong discussion of how the CIH workforce could be better mobilized during future crises. In this article, the authors summarize the key barriers identified in the discussion and make recommendations on how they can be overcome.

A Scoping Review of Chronic Low Back Pain Classification Schemes Based on Patient-Reported Outcomes.

BACKGROUND: In 2014, the National Institutes of Health Pain Consortium Research Task Force recommended that patients with chronic low back pain (CLBP) be stratified by its impact on their lives. They proposed the Impact Stratification Score (ISS) to help guide therapy and facilitate study comparability. The ISS has been evaluated as a continuous measure, but not for use as a stratification or classification scheme. OBJECTIVES: Identify the characteristics of successful schemes to inform the use of the ISS for stratification or classification. STUDY DESIGN: Scoping review of the peer-reviewed literature. METHODS: Search of PubMed, CINAHL, and APA PsycInfo to identify patient self-report-based classification schemes applicable to CLBP. Data were captured on the methods used for each scheme's development, the domains covered, their scoring criteria and what the classification has successfully measured. The study was reviewed and approved by the RAND Human Subjects Protection Committee (2019-0651-AM02). RESULTS: The search identified 87 published articles about the development and testing of 5 classification schemes: 1) The Subgroups for Targeted Treatment (STarT) Back Screening Tool, 2) Multiaxial Assessment of Pain, 3) Graded Chronic Pain Scale, 4) Back Pain Classification Scale, and 5) Chronic Pain Risk Score. All have been shown to be predictive of future outcomes and the STarT Back has been found useful in identifying effective classification-specific treatment. Each scheme had a different classification scoring structure, was developed using different methods, and 3 included domains not found in the ISS. LIMITATIONS: Expanding the search to other databases may have identified more classification schemes. Our minimum number of publications inclusion criterion eliminated dozens of cluster analyses, some of which may have eventually been replicated. CONCLUSIONS: The methods used to develop these successful classification schemes, especially those that use straightforward scoring schemes, should be considered for use in the development of a scheme based on the ISS.

Health-Related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care Plus Chiropractic Care vs Usual Care Alone: Secondary Outcomes of a Pragmatic Clinical Trial.

OBJECTIVE: This study examines Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0-10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale). DESIGN: A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC). SETTING: Three military treatment facilities. SUBJECTS: 750 active-duty military personnel with low back pain. METHODS: Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change. RESULTS: We found statistically significant mean group differences favoring UMC+CC for all PROMIS®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS®-29 scales and the RMDQ, ranged from 0.79 to 0.83. CONCLUSIONS: Findings from this pre-planned secondary analysis demonstrate that chiropractic care impacts health-related quality of life beyond pain and pain-related disability. Further, comparable findings were found between the 24-item RMDQ and the PROMIS®-29 v1.0 briefer scales.

Barriers to the Engagement of Complementary and Integrative Health Providers in Public Health Responses to COVID-19: Recommendations From a Multidisciplinary Expert Panel.

OBJECTIVE: The purpose of this project was to explore barriers to the involvement of complementary and integrative health (CIH) providers in the public health response to COVID-19 and potential solutions for future involvement in public health crises. METHODS: An expert panel of 10 people, which included doctors of chiropractic, naturopathic doctors, public health practitioners, and researchers from the United States, was convened for a day-long online panel discussion. Facilitators asked panelists how CIH practitioners could contribute and be mobilized. We summarized themes and recommendations from the discussion. RESULTS: Despite their skills and resources, few CIH providers participated in public health efforts like testing and contact tracing during the COVID-19 pandemic. Panelists described that CIH professionals may not have participated in those efforts due to the CIH providers possibly not having sufficient public health training and limited contact with public health professionals, as well as policy and financial challenges during the pandemic. Panelists proposed solutions to these barriers, including more public health training, stronger formal relationships between CIH and public health organizations, and improved financial support for both CIH care and public health efforts. CONCLUSION: Through an expert panel discussion, we identified barriers that hindered the involvement of CIH providers in the public health response to the COVID-19 pandemic. During future pandemics in the United States, public health planners should recognize CIH providers as part of the existing labor resource, with clinical expertise and community-level connections that can be called upon in a crisis. During future events, CIH professional leaders should be more proactive in seeking out a supportive role and sharing their knowledge, skills, and expertise.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain.

OBJECTIVES: The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States. METHODS: We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income. RESULTS: Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively. CONCLUSIONS: Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Measuring the Appropriateness of Spinal Manipulation for Chronic Low Back and Chronic Neck Pain in Chiropractic Patients.

STUDY DESIGN: RAND/UCLA Appropriateness Method (RUAM) applied to chiropractic manipulation for patients with chronic low-back pain (CLBP) and chronic neck pain (CNP). OBJECTIVE: Determine the rate of appropriate care provided by US chiropractors. SUMMARY OF BACKGROUND DATA: Spinal manipulation has been shown effective for CLBP and CNP but may not be appropriate for all patients with these conditions. METHODS: Ratings of the appropriateness of spinal and cervical manipulation previously developed by two RUAM expert panels were applied to data abstracted from random samples of patient charts from chiropractors in six US regions to determine the appropriateness of manipulation for each patient. RESULTS: Of 125 chiropractors sampled, 89 provided charts that could be abstracted. Of the 2128 charts received, 1054 were abstracted. Charts received but not abstracted included 460 that were unusable (e.g., illegible), and 555 did not have CLBP or CNP. Across the abstracted charts 72% had CLBP, 57% had CNP, and 29% had both; 84% of patients with CLBP and 86% with CNP received manipulation. Patients with CLBP who had minor neurologic findings, sciatic nerve irritation, or no joint dysfunction were significantly less likely to receive manipulation. Patients with CNP who had substantial trauma etiology, no joint dysfunction, or no radiographs were significantly less likely to receive manipulation. Most manipulation for CLBP (64%) was appropriate and most manipulation for CNP (93%) was for patients where appropriateness was uncertain or equivocal. The proportions of patients receiving inappropriate manipulation for either condition were low (1%-3%) as were the numbers of patients presenting to these chiropractors for which manipulation was inappropriate. CONCLUSION: Chiropractors in this US sample tend to provide manipulation to very few patients with CLBP or CNP for which it is inappropriate. However, more research is needed to determine which patients with CNP benefit from manipulation.Level of Evidence: 4.

Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit.

OBJECTIVE: The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria. METHODS: We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions. RESULTS: Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification. CONCLUSION: Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

Visit Frequency and Outcomes for Patients Using Ongoing Chiropractic Care for Chronic Low-Back and Neck Pain: An Observational Longitudinal Study.

BACKGROUND: Chronic spinal pain is prevalent and long-lasting. Although provider-based nonpharmacologic therapies, such as chiropractic care, have been recommended, healthcare and coverage policies provide little guidance or evidence regarding long-term use of this care. OBJECTIVE: To determine the relationships between visit frequency and outcomes for patients using ongoing chiropractic care for chronic spinal pain. STUDY DESIGN: Observational 3-month longitudinal study. SETTING: Data collected from patients of 124 chiropractic clinics in 6 United States regions. METHODS: We examined the impact of visit frequency and patient characteristics on pain (pain 0-10 numeric rating scale) and functional outcomes (Oswestry Disability Index [ODI] for low-back pain and Neck Disability Index [NDI] for neck pain, both 0-100 scale) using hierarchical linear modeling (HLM) in a large national sample of chiropractic patients with chronic low back pain (CLBP) and/or chronic neck pain (CNP). This study was approved by the RAND Human Subjects Protection Committee and registered under ClinicalTrials.gov Identifier: NCT03162952. RESULTS: One thousand, three hundred, sixty-two patients with CLBP and 1,214 with CNP were included in a series of HLM models. Unconditional (time-only) models showed patients on average had mild pain and function, and significant, but slight improvements in these over the 3-month observation period: back and neck pain decreased by 0.40 and 0.44 points, respectively; function improved by 2.7 (ODI) and 3.0 points (NDI) (all P < 0.001). Adding chiropractic visit frequency to the models revealed that those with worse baseline pain and function used more visits, but only visits more than once per week for those with CLBP were associated with significantly better improvement. These relationships remained when other types of visits and baseline patient characteristics were included. LIMITATIONS: This is an observational study based on self-reported data from a sample representative of chiropractic patients, but not all patients with CLBP or CNP. CONCLUSIONS: This 3-month window on chiropractic patients with CLBP and/or CNP revealed that they were improving, although slowly; may have reached maximum therapeutic improvement; and are possibly successfully managing their chronic pain using a variety of chiropractic visit frequencies. These results may inform payers when building coverage policies for ongoing chiropractic care for patients with chronic pain.

Comparing the Recruitment of Research Participants With Chronic Low Back Pain Using Amazon Mechanical Turk With the Recruitment of Patients From Chiropractic Clinics: A Quasi-Experimental Study.

OBJECTIVE: The purpose of this study was to compare the crowdsourcing platform Amazon Mechanical Turk (MTurk) with in-person recruitment and web-based surveys as a method to (1) recruit study participants and (2) obtain low-cost data quickly from chiropractic patients with chronic low back pain in the United States. METHODS: In this 2-arm quasi-experimental study, we used in-person clinical sampling and web-based surveys from a separate study (RAND sample, n = 1677, data collected October 2016 to January 2017) compared with MTurk (n = 310, data collected November 2016) as a sampling and data collection tool. We gathered patient-reported health outcomes and other characteristics of adults with chronic low back pain receiving chiropractic care. Parametric and nonparametric tests were run. We assessed statistical and practical differences based on P values and effect sizes, respectively. RESULTS: Compared with the RAND sample, the MTurk sample was statistically significantly younger (mean age 35.4 years, SD 9.7 vs 48.9, SD 14.8), made less money (24% vs 17% reported less than $30,000 annual income), and reported worst mental health than the RAND sample. Other differences were that the MTurk sample had more men (37% vs 29%), fewer White patients (87% vs 92%), more Hispanic patients (9% vs 5%), fewer people with a college degree (59% vs 68%), and patients were more likely to be working full time (62% vs 58%). The MTurk sample was more likely to have chronic low back pain (78% vs 66%) that differed in pain frequency and duration. The MTurk sample had less disability and better global health scores. In terms of efficiency, the surveys cost $2.50 per participant in incentives for the MTurk sample. Survey development took 2 weeks and data collection took 1 month. CONCLUSION: Our results suggest that there may be differences between crowdsourcing and a clinic-based sample. These differences range from small to medium on demographics and self-reported health. The low incentive costs and rapid data collection of MTurk makes it an economically viable method of collecting data from chiropractic patients with low back pain. Further research is needed to explore the utility of MTurk for recruiting clinical samples, such as comparisons to nationally representative samples.

Chiropractic Services and Diagnoses for Low Back Pain in 3 U.S. Department of Defense Military Treatment Facilities: A Secondary Analysis of a Pragmatic Clinical Trial.

OBJECTIVE: The purpose of this study was to describe the diagnoses and chiropractic services performed by doctors of chiropractic operating within 3 military treatment facilities for patients with low back pain (LBP). METHODS: This was a descriptive secondary analysis of a pragmatic clinical trial comparing usual medical care (UMC) plus chiropractic care to UMC alone for U.S. active-duty military personnel with LBP. Participants who were allocated to receive UMC plus 6 weeks of chiropractic care and who attended at least 1 chiropractic visit (n = 350; 1547 unique visits) were included in this analysis. International Classification of Diseases and Current Procedural Terminology codes were transcribed from chiropractic treatment paper forms. The number of participants receiving each diagnosis and service and the number of each service on unique visits was tabulated. Low back pain and co-occurring diagnoses were grouped into neuropathic, nociceptive, bone and/or joint, general pain, and nonallopathic lesions categories. Services were categorized as evaluation, active interventions, and passive interventions. RESULTS: The most reported pain diagnoses were lumbalgia (66.1%) and thoracic pain (6.6%). Most reported neuropathic pain diagnoses were sciatica (4.9%) and lumbosacral neuritis or radiculitis (2.9%). For the nociceptive pain, low back sprain and/or strain (15.8%) and lumbar facet syndrome (9.2%) were most common. Most reported diagnoses in the bone and/or joint category were intervertebral disc degeneration (8.6%) and spondylosis (6.0%). Tobacco use disorder (5.7%) was the most common in the other category. Chiropractic care was compromised of passive interventions (94%), with spinal manipulative therapy being the most common, active interventions (77%), with therapeutic exercise being most common, and a combination of passive and active interventions (72%). CONCLUSION: For the sample in this study, doctors of chiropractic within 3 military treatment facilities diagnosed, managed, and provided clinical evaluations for a range of LBP conditions. Although spinal manipulation was the most commonly used modality, chiropractic care included a multimodal approach, comprising of both active and passive interventions a majority of the time.

Experiences With Chiropractic Care for Patients With Low Back or Neck Pain.

BACKGROUND: Musculoskeletal disorders are the second leading cause of disability worldwide. OBJECTIVE: Examine experiences of chiropractic patients in the United States with chronic low back or neck pain. METHOD: Observational study of 1853 chronic low back pain and neck pain patients (74% female) who completed an online questionnaire at the 3-month follow-up that included Consumer Assessment of Healthcare Providers and Systems (CAHPS) items assessing their experiences with care. RESULTS: We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points). CONCLUSIONS: The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Update of Markov Model on the Cost-effectiveness of Nonpharmacologic Interventions for Chronic Low Back Pain Compared to Usual Care.

STUDY DESIGN: Markov model. OBJECTIVE: Further validity test of a previously published model. SUMMARY OF BACKGROUND DATA: The previous model was built using data from ten randomized trials and examined the 1-year effectiveness and cost-effectiveness of 17 nonpharmacologic interventions for chronic low back pain (CLBP), each compared to usual care alone. This update incorporated data from five additional trials. METHODS: Based on transition probabilities that were estimated using patient-level trial data, a hypothetical cohort of CLBP patients transitioned over time among four defined health states: high-impact chronic pain with substantial activity limitations; higher (moderate-impact) and lower (low-impact) pain without activity limitations; and no pain. As patients transitioned among health states, they accumulated quality-adjusted life-years, as well as healthcare and productivity costs. Costs and effects were calculated incremental to each study's version of usual care. RESULTS: From the societal perspective and assuming a typical patient mix (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain), most interventions-including those newly added-were cost-effective (<$50,000/QALY) and demonstrated cost savings. From the payer perspective, fewer were cost-saving, but the same number were cost-effective. Results for the new studies generally mirrored others using the same interventions-for example, cognitive behavioral therapy (CBT) and physical therapy. A new acupuncture study had similar effectiveness to other acupuncture studies, but higher usual care costs, resulting in higher cost savings. Two new yoga studies' results were similar, but both differed from those of the original yoga study. Mindfulness-based stress reduction was similar to CBT for a typical patient mix but was twice as effective for those with high-impact chronic pain. CONCLUSION: Markov modeling facilitates comparisons across interventions not directly compared in trials, using consistent outcome measures after balancing the baseline mix of patients. Outcomes also differed by pain impact level, emphasizing the need to measure CLBP subgroups. LEVEL OF EVIDENCE: N/A.

Predictors of visit frequency for patients using ongoing chiropractic care for chronic low back and chronic neck pain; analysis of observational data.

BACKGROUND: Chronic spinal pain is prevalent, expensive and long-lasting. Several provider-based nonpharmacologic therapies have now been recommended for chronic low-back pain (CLBP) and chronic neck pain (CNP). However, healthcare and coverage policies provide little guidance or evidence regarding the long-term use of this care. To provide one glimpse into the long-term use of nonpharmacologic provider-based care, this study examines the predictors of visit frequency in a large sample of patients with CLBP and CNP using ongoing chiropractic care. METHODS: Observational data were collected from a large national sample of chiropractic patients in the US with non-specific CLBP and CNP. Visit frequency was defined as average number of chiropractic visits per month over the 3-month study period. Potential baseline predictor variables were entered into two sets of multi-level models according to a defined causal theory-in this case, Anderson's Behavioral Model of Health Services Use. RESULTS: Our sample included 852 patients with CLBP and 705 with CNP. Visit frequency varied significantly by chiropractor/clinic, so our models controlled for this clustering. Patients with either condition used an average of 2.3 visits per month. In the final models visit frequency increased (0.44 visits per month, p = .008) for those with CLBP and some coverage for chiropractic, but coverage had little effect on visits for patients with CNP. Patients with worse function or just starting care also had more visits and those near to ending care had fewer visits. However, visit frequency was also determined by the chiropractor/clinic where treatment was received. Chiropractors who reported seeing more patients per day also had patients with higher visit frequency, and the patients of chiropractors with 20 to 30 years of experience had fewer visits per month. In addition, after controlling for both patient and chiropractor characteristics, the state in which care was received made a difference, likely through state-level policies and regulations. CONCLUSIONS: Chiropractic patients with CLBP and CNP use a range of visit frequencies for their ongoing care. The predictors of these frequencies could be useful for understanding and developing policies for ongoing provider-based care.

Computerized adaptive testing and short form development for child and adolescent oral health patient-reported outcomes measurement.

OBJECTIVES: To develop computerized adaptive testing (CAT) and short forms of self-report oral health measures that are predictive of both the children's oral health status index (COHSI) and the children's oral health referral recommendation (COHRR) scales, for children and adolescents, ages 8-17. MATERIAL AND METHODS: Using final item calibration parameters (discrimination and difficulty parameters) from the item response theory analysis, we performed post hoc CAT simulation. Items most frequently administered in the simulation were incorporated for possible inclusion in final oral health assessment toolkits, to select the best performing eight items for COHSI and COHRR. RESULTS: Two previously identified unidimensional sets of self-report items consisting of 19 items for the COHSI and 22 items for the COHRR were administered through CAT resulting in eight-item short forms for both the COHSI and COHRR. Correlations between the simulated CAT scores and the full item bank representing the latent trait are r = .94 for COHSI and r = .96 for COHRR, respectively, which demonstrated high reliability of the CAT and short form. CONCLUSIONS: Using established rigorous measurement development standards, the CAT and corresponding eight-item short form items for COHSI and COHRR were developed to assess the oral health status of children and adolescents, ages 8-17. These measures demonstrated good psychometric properties and can have clinical utility in oral health screening and evaluation and clinical referral recommendations.

Clinical Scenarios for Which Cervical Mobilization and Manipulation Are Considered by an Expert Panel to Be Appropriate (and Inappropriate) for Patients With Chronic Neck Pain.

OBJECTIVES: Cervical mobilization and manipulation are 2 therapies commonly used for chronic neck pain (CNP). However, safety, especially of cervical manipulation, is controversial. This study identifies the clinical scenarios for which an expert panel rated cervical mobilization and manipulation as appropriate and inappropriate. METHODS: An expert panel, following a well-validated modified-Delphi approach, used an evidence synthesis and clinical acumen to develop and then rate the appropriateness of cervical mobilization and manipulation for each of an exhaustive list of clinical scenarios for CNP. Key patient characteristics were identified using decision tree analysis (DTA). RESULTS: Three hundred seventy-two clinical scenarios were defined and rated by an 11-member expert panel as to the appropriateness of cervical mobilization and manipulation. Across clinical scenarios more were rated inappropriate than appropriate for both therapies, and more scenarios were rated inappropriate for manipulation than mobilization. However, the number of patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included red flags (eg, fever, cancer, inflammatory arthritides, or vasculitides), and some others involving major neurological findings, especially if previous manual therapy was unfavorable, were rated as inappropriate for both cervical mobilization and manipulation. DTA also identified the absence of cervical disk herniation, stenosis, or foraminal osteophytosis on additional testing as the most important patient characteristic in predicting ratings of appropriate. CONCLUSIONS: Clinical guidelines for CNP should include information on the clinical scenarios for which cervical mobilization and manipulation were found inappropriate, including those with red flags, and others involving major neurological findings if previous manual therapy was unfavorable.